"Pharmaceutical practices in Southeast Asia 8-9 June 2015, Chulalongkorn University Alumni Room

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1 "Pharmaceutical practices in Southeast Asia 8-9 June 2015, Chulalongkorn University Alumni Room Funding : Partenariat Hubert Curien SIAM Organized by Workshop organisé par Audrey Bochaton (Nanterre), Supang Chantanavich (Chulalongkorn University), Niyada Kiatying-Angsulee (Chulalongkorn University), Mathieu Quet (IRD), Laurent Pordié (Cermes3) et Premjai Vungsiriphisal (Chulalongkorn University). Institutions: Institute of Asian Studies, Chulalongkorn University, Drug System Monitoring and Development Program, Institut de Recherche pour le Développement This workshop is dedicated to the analysis of pharmaceutical practices - production, distribution, consumption - in South East Asia. It gathers an interdisciplinary team of specialists from the social sciences (anthropology, communication, geography, political science) and from the pharmaceutical sciences in order to discuss the issue of pharmaceutical flows in South East Asia in the context of the economic integration of the ASEAN. Monday 8 June 2015 ***** Introduction 9h: Audrey Bochaton, Supang Chantanavich, Laurent Pordié, Mathieu Quet - Illicit circulations of medicines in Southeast Asia Morning Session 9h30 : Marie Lamy - Understanding and explaining the presence of falsified antimalarial drugs in the Greater Mekong Subregion 10h00 : Boravann Mam - The circulation of uncontrolled pharmaceutical products in Southeast Asia and Cambodia

2 10h30 : Pascale Hancart-Petitet - Dissemination and regulation of abortion pills in Southeast Asia: products, actors and logics in action 11h00 : Niyada Kiatying-Angsulee - title to be confirmed 11h30 : Eve Bureau - Antimalarial medicines and market regulations in Cambodia 12h00 : Supang Chantanavich and Premjai Vungsiriphisal - title to be confirmed Afternoon Session 14h00 : Evelyne Micollier - Circulations and uses of Chinese medicines in Southeast Asia (Greater Mekong Subregion) 14h30 : Céline Caillet - Unidentified single units of medicines in the Lao People s Democratic Republic: a visual identification tool 15h00 : Chanvilay Sichanh - title to come 15h30 : Céline Coderey - Which accessibility to biomedical pharmaceuticals in Myanmar? 16h00 : Hélène Lépinay - Consumption of medicines by HIV-positive teenagers in Thailand Conclusion 17h00 : Audrey Bochaton & Supang Chantanavich ***** Tuesday 9 June h - 13h : Collective discussion about the interest and possibility of a collective and interdisciplinary project (anthropology - communication - geography - pharmaceutical sciences - political science - sociology)

3 ABSTRACTS Illicit circulations of medicines in Southeast Asia Audrey Bochaton (Geography, Université Paris Ouest), Laurent Pordié (Anthropology, CNRS), Mathieu Quet (Communication, IRD) Until recently, social sciences have studied biomedical drugs more frequently in highly industrialized countries and few attention has been paid to the circulation of medical products in the global south (Hayden 2007) except in the case of antiretrovirals (Sell 2007 ; Nguyen 2007, Biehl 2008). The objective of this research project is to address simultaneously the multiplicity of circulation modes and the lifecycle of medical commodities (Reynolds Whyte 2002; Appadurai 1996) in a context of South-South circulations in South-East Asia. The emphasis on strongly regulated Northern markets has led to neglect regulatory issues specific to Southern markets, except in some works dedicated to African countries (Fassin 1986, Baxerres 2014, Peterson 2012) and works in South-East Asia (Newton et al., 2008). The project s focus upon illicit circulations is analytical and not normative. It enables us to describe the regulation of drugs and the standardization of Asian pharmaceutical markets as dynamic processes during which national and transnational regulatory standards meet distribution and consumption practices oscillating between formality and informality. During the regulatory processes, the status of medicines (whether they are licit or illicit) is produced through negotiations between heterogeneous actors and sets of standards which need to be documented further. The main hypothesis of the project is that access to medicines is reconfigured by the emergence of new circulation modes (licit and illicit) framed by globalization processes. If access to medicines is highly determined by the characteristics of healthcare available in a country, it does not depend only on national health institutions. According to the context, medicines can be bought as well in licensed pharmacies as in unlicensed ones, in markets, in herbal shops or food shops, on internet, etc. In that context, access to medicines is both depending on national health institutions as informal commercial networks. Moreover, with the economic integration of the ASEAN Economic Community (AEC) by the end of 2015, agreements on trade, services and investment will change the economic landscape and allow the freer flow of goods, services and people across the region. In the pharmaceutical sector, the most significant impact of AEC will be a contradictory move. On one hand, integration will correspond to the harmonization of pharmaceutical standards. On the other hand, the end of customs might increase informal transnational circulations, among which illicit medicines. This contradictory move (standardization vs increasing informal flows) will be analyzed at the policy level as well as at the local level of retailing and consumption practices.

4 Understanding and explaining the presence of falsified antimalarial drugs in the Greater Mekong Subregion. Marie Lamy (Political science, London School of Hygiene & Tropical Medicine) The World Health Organization (WHO) estimates the global market in fake medicines to be in excess of US$75 billion. The illicit trade in fake drugs therefore represents a pressing public health concern. The Greater Mekong Subregion (GMS) in particular, has a large concentration of falsified medicines, especially of antimalarial and tuberculosis drugs. This poses a considerable threat to human lives and an obstacle to infectious disease control, also due to the associated risk of antimicrobial resistance. Despite past efforts from GMS governments to tackle this issue, and regardless of lower prevalence rates of fake antimalarial drugs estimated in Thailand, Lao PDR and Cambodia, the problem of fake medicines persists. We still have a limited understanding of the reasons why fake antimalarial drugs are still prevalent in the GMS. Additionally, there is no comprehensive single study evaluating the governance landscape of Southeast Asia with regards to falsified medicines. As trade liberalization in Southeast Asia intensifies, there are concerns that reduced custom controls and higher mobility of people and goods may cause further increase in this illicit trade. In this context, it is crucial to understand the complexity of this multi-faceted public health challenge. This research project addresses an apparent gap in the literature by providing empirical evidence of the factors that might contribute or facilitate the illicit trade in fake antimalarial drugs in the GMS. The circulation of uncontrolled pharmaceutical products in Southeast Asia and Cambodia Boravann Mam (Public Private Partnership Supervisor, Cambodia National Malaria Center) The presentation will deal with the circulation of non-regulated industrial medical drugs. Personal enquiries have been conducted is nowadays at the crossroads of maritime, aerial and terrestrial roads which are conditioning the destination and passage of both illegal and lowquality drugs. In that respect, a second section is interested with the geo-policy of the counterfeit products. We give instances of the modalities of the production of the illicit substances, and we describe security mechanisms that have prepared for tackling social counterfeit networks. Reference at the global level is therefore indispensable because the geographical distance is no more an obstructive component. Third section states the legal, material and human means of control that have been implemented for improving better pharmaceutical procurement and distribution. We estimate that it is crucial to identify ongoing misunderstandings, contradictions and hazards because of the cumulative association of these factors liable to threaten an integrated strategy. A fourth section is giving a close eye to the

5 recent dynamics of struggle against the traffic in the Lower Mekong Sub-region, with Cambodia as an epicenter. Main concerted actions and strategies are depicted, with a particular attention focusing on collaborative mechanisms that exist (or not) between national authorities, NGOs and international agencies. Dissemination and regulation of abortion pills in Southeast Asia: products, actors and logics in action Pascale Hancart Petitet (Anthropology, IRD) In Southern countries many women are still dying from illegal and harmful abortions practices. Access to legal abortion pill represents a major step forward for women health and rights. In Cambodia, one of these methods is commonly called the Chinese pill, a combination of mifepristone and misoprosol used for its contraceptive and abortifacient effects. This is one of the "non-registered" drugs by the Cambodian Ministry of Health. Chinese pills are sold in pharmacies; they are also available in the markets, from street vendors, rural practitioners or DJ working in karaoke. In 2010, after its approval by the Ministry of Health, the product Medabon was sold in pharmacies and in a limited number of health institutions. This product that combines mifepristone and misoprostol is issued from collaboration between a charitable organization headquartered in Bangkok and a pharmaceutical industry based in India. There is a need to analyze the complex trade-offs between various actors at national and transnational levels that shape the diffusion and the regulating processes of the abortion pill. Medications for daily living : a window to understand the Cambodian market of pharmaceuticals Eve Bureau (Anthropology, IRD) Pharmaceutical drugs provide an ideal window into studying contemporary societies and understanding how and why they change. With dimensions that are simultaneously scientific, therapeutic, popular and commercial, drugs are central to the health, economic, political and social issues in play, both on a global and local scale. The general objectif of the study is to do a research about the Cambodian pharmaceutical system, by conducting a case study on the medications for daily living (curative, preventive, health maintaining), the uses of medicines of Cambodian people and the retailers practices. This study is part of a research program conducted also in one French and one English speaking countries of West Africa, Benin and Ghana. The hypothesis guiding our research is that the modes of pharmaceutical distribution have an impact on drug uses and consumption, which tend to increase and go beyond the scope of biomedical recommendations. Field work consist in investigation conducted with 20

6 families with different socio-economic status, half living in an urban area (Phnom Penh), the other half living in a rural area (not identified yet): in-depth interviews with the mother and in some of the families with the father and a possible third person (grand-mother, aunt, etc.), inventory of household s pharmacies and a four month bi-monthly follow-up of the consumption of medicines of each member of the families. In addition, we conducted interviews and observations in the different places where they get medicines, with other key actors of distribution and with different kind of stakeholders involved in the Cambodian pharmaceutical system. This 18 month post-doctorale research has started in January The purpose of the communication is to present the rationale, the method and preliminary results of the research. Circulations and uses of Chinese medicines in Southeast Asia (Greater Mekong Subregion) Evelyne Micollier (Anthropology, IRD) Chinese medicines are mainly industrial pharmaceuticals made in China by Chinese (private, state, mixed status) or China-foreign (joint-- ventures) corporates. These products are either biomedical products of synthetic or natural origin or traditional products transformed into industrial pharmaceuticals. The pharmaceutics industrial sector largely contributes to their R&D process. Chinese contemporary pharmacopeia registered within the WHO framework in line with the norm of the international organization and updated every other year, does not distinguish industrial pharmaceuticals from Asian therapeutic traditions than those from biomedicine. Medicines circulate following complex trajectories involving a number of actors to be identified, far away or not so from production and R&D sites in line with their degree of integration into the health global market. Firstly their nature, status and legitimacy need to be carefully scrutinized while regulations in the Mekong region are not standardized producing blurred borders between licit and illicit products. Secondly while trajectories, itineraries and networks of exchanges are historical, emerging or re-emerging between China and the greater region, these issues are worth to be investigated within the framework of the AEC building up. The proposal is programmatic building on theoretical & methodological keys, case studies used in previous research about Chinese medicine and its globalizing process with the objective to focus on Chinese medicines circulating in Southeast Asia and their uses in differentiated contexts.

7 Unidentified single units of medicines in the Lao People s Democratic Republic: a visual identification tool Céline Caillet (Pharmaceutical Sciences, Toulouse University) In countries where medicines are frequently removed from their original packaging and dispensed without labeling (i.e without providing the name of the medicine or its active ingredient nor its strength), tools of identification are needed to support patients, healthcare professionals and researchers facing unknown pharmaceutical units. Aim : To assess a visual tool for the identification of units of medicines in the Lao People s Democratic Republic (Lao PDR). Methods : Three health workers, blinded to medicine identity, used two methods to identify 103 units of medicines randomly selected from a collection of classified units collected in Vientiane pharmacies. In the contact method they were allowed to handle the reference units whereas in the picture method, electronic photographs of the reference units were compared to the unknown unit. Results : Accuracies of 92.5% and 80.6% were observed for the contact and picture methods, respectively, against reference identity. Reproducibility was almost perfect and substantial for the contact and picture methods, respectively. The picture method was less accurate than the contact method to identify un-imprinted medicines. Among the collected medicines with imprints on tablets and capsules (n=281), 7.8% had at least one look-alike unit, mostly with a different active pharmaceutical ingredient. Discussion : The high accuracy and convenience of the picture method make it worth considering for wider use, whereas the contact method, of higher accuracy, could be useful for research investigations. Ambiguously labelled look-alike tablets/capsules from different pharmacological classes may expose patients to risk of medication errors. Health authorities should be encouraged to implement visual tools of identification. Improvements in the unambiguous imprinting of tablets/capsules by the pharmaceutical industry should be a global priority. Which accessibility to biomedical pharmaceuticals in Myanmar? Celine Coderey (Anthropology, Asia Research Institute, NUS) Based on several fieldwork trips I have conducted in Myanmar, and particularly in Rakhine State, since 2005, I intend to outline the local pharmaceutical offer and its accessibility. The analysis will include two steps: - I will first describe how the production, circulation and distribution of pharmaceuticals is regulated by the national and international health authorities and how it does actually take place. In particular, I intend to highlight that the long-lasted neglect of the health sector from

8 the part of the military government, the exclusion from most of the forms of multilateral development assistance and the historical hierarchical relationship between the bamadominated center and the peripheries inhabited by minority groups have largely contributed to the current scarcity of medicines (and more generally the important weaknesses of the health system) especially in the peripheral areas and in specialist sectors (for instance, mental health, reproductive health, HIV), the almost absence of local products, the increasing illegal import and the sell of medicines coming from the border (Bangladesh, Thailand and China) as well as the reintroduction into the market of products originally imported by NGO, the spread of counterfeits as well as of products recognized as food supplements but promoted and sold as medicines, the high cost of the medicines and the absence of a medical insurance system. -Secondly, I ll describe how the population apprehends this offer and how it deals with it. Through some ethnographic examples (mainly concerning contraceptive products and HIV medications), I will outline how depending on where the live (center of periphery), their socioeconomical and educational conditions, their family traditions and health habits, their exposition to media and health promotion messages, people largely differ in their attitude toward biomedical products (trust vs fear, familiarity vs unfamiliarity, dangerosity) and in their choices in matters of medicines and health services. Consumption of medicines by HIV-positive teenagers in Thailand Hélène Lépinay To be completed ******************************** Missing abstracts: - Supang Chantanavich (Sociology, Chulalongkorn University) - Niyada Kiatying-Angsulee (Pharmaceutical Sciences, Chulalongkorn University) - Chanvilay Sichanh (Drug Quality Group Assistant, Worldwide Antimalarial Resistance Network) - Lao